Basic Information
| Provider Information | |||||||||
| NPI: | 1417215989 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH TEXAS AREA COMMUNITY HEALTH CENTERS, INC. | ||||||||
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| OtherOrganizationName: | WISE COUNTY COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 N MAIN ST | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761648570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173780855 | ||||||||
| FaxNumber: | 8173780861 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 S FM 51 | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403930100 | ||||||||
| FaxNumber: | 9403930199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/23/2013 | ||||||||
| NPIReactivationDate: | 01/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | VIVEROS | ||||||||
| AuthorizedOfficialFirstName: | ARCADIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8173780855 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.